QOL Improvements of Scoliosis Surgery in Children With Cerebral Palsy Outweigh Risks

Scoliosis surgery significantly improves quality of life (QOL) in children with cerebral palsy, according to findings from a prospective, longitudinal study in the April 4 issue of The Journal of Bone and Joint Surgery. While scoliosis surgery is linked to a higher risk for complications in this population, the benefits outweigh the risks, according to the study authors.Scoliosis surgery in a child with cerebral palsy may halt curve progression and improve quality of life.“This study provides evidence that surgery for scoliosis in patients with cerebral palsy provides a meaningful, positive impact on QOL,” said lead author Firoz Miyanji, MD, FRCS(C), Investigator at BC Children's Hospital, and Clinical Associate Professor of Orthopedics at the University of British Columbia in Vancouver.

Nearly two-thirds of severely impaired, non-ambulatory patients with cerebral palsy have progressive scoliosis, which can lead to pain and decreased QOL as well as cardiopulmonary and gastrointestinal function, the researchers explained. While surgery is often used to halt curve progression, the benefit of scoliosis surgery in this population is the topic of ongoing debate. Notably, scoliosis surgery is associated with a high rate of perioperative complications, with rates ranging from 17% to 74% in previous studies, the researchers explained.

Children Followed for 5 Years After Scoliosis Surgery
The study included 69 children (mean age 13.4 years at enrollment) with cerebral palsy who underwent spinal fusion for scoliosis between 2008 and 2011. The children had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy, and were followed prospectively for 5 years after surgery.

Mean major Cobb angle improved from 81.9° pre-operatively to 28.7° at 2 years and 30.7° at 5 years post-operatively. Significant improvements in overall QOL, as assessed using the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire, were noted at 1, 2, and 5-year follow-up evaluations (Table). Overall 92% of caregivers rated their child’s QOL as improved at 1 year following scoliosis surgery; 6.3% reported deterioration.Mean Change in CPCHILD Scores at 1, 2, and 5 Years Following Scoliosis Surgery in Children With Cerebral PalsyHigh Rate of Complications Found
The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years post-operatively. The most common complications were pneumonia and surgical site infection.

Six patients required surgical intervention within 1 year, and 2 additional patients within 5 years. Complications were not correlated with CPCHILD scores post-operatively at any time points, with the exception of a weak correlation (ρ=–0.450, P=0.002) between complication rate and CPCHILD comfort score at 1 year after surgery.

Are Non-surgical Options Effective for Scoliosis in Patients With Cerebral Palsy?
“Bracing has not been shown to be effective in preventing curve progression, but may help in sitting balance or maintaining an upright posture,” Dr. Miyanji said. He added that wheelchair modification and lateral supports also may aid in maintaining an upright sitting posture, and are likely more practical than bracing.

“Unfortunately, for progressive curves, surgery may need to be considered to halt the progression and obtain curve correction,” Dr. Miyanji told SpineUniverse.

Risks vs Benefits of Spinal Fusion in Cerebral Palsy
Weighing the risk for complications versus the benefits of spinal fusion is “one of the most compelling challenges of whether or not to move forward with spinal fusion in this patient population,” Dr. Miyanji noted. “Our study now provides meaningful information that despite the high complication rate of surgery in this fragile population, the impact on quality of life outweighed the complication risk in our cohort.”

However, “the results are not granular to suggest that all patients should undergo surgery,” Dr. Miyanji concluded. “This ultimate decision should still be made collectively between the treating surgeon, patient, family, and caregivers, with individualized goals of surgery and outcomes [determined for] each patient. We are hopeful that this study will allow treating surgeons and families to have a better discussion of ‘what to expect’ if surgery were to be undertaken, especially in terms of QOL.”

Disclosure
Dr. Miyanji has received research grant support from DePuy Synthes Spine.